Book Review: Carbohydrates in Food

household indicators including hygienic practices, bednet use, breastfeeding, micronutrient consumption, tobacco and alcohol use, sexual practices, domestic violence, education, exposure to mass media, knowledge of and attitudes to HIV-AIDS, and status of women (household decision-making, freedom of movement, other decision-making), and status of orphans. What did the Reaching the Poor studies find? The emphasis was on demonstrating the research method rather than on guidance applicable to only a few countries and topics. However, the overall conclusion was that “much better distributional performance on the part of health, nutrition and populations programs is possible.” The three studies of nutrition programs are all from Latin America. In Argentina, the incidence changes resulting from public health and nutrition programs in the five years of the study favored the “nonpoor.” In Brazil, health coverage was lower among the poor for the two universal programs studied, immunization and antenatal care. The recommendations included an increase in the number of and access to service units, improved access to referral services, increased monitoring and evaluation, and feedback of the results. In Peru, the main problem was reaching the poor with nutrition programs, but “further research is definitely needed before any action is taken.” These studies provide insights into how well largescale nutrition and health programs reach the poor, but improving their targeting will not be easy. A general conclusion is that better approaches to service delivery are needed if the poor are to be reached effectively. Some health workers will be interested in applying the methodology, and many will benefit from exploring this wealth of program data for application to their own national nutrition and other health programs.

the former it was connected with slight and almost doubtful coagulation of the urine by heat; in the latter I had omitted to examine the state of the urine. I also met with nearly the same condition of the kidney, with some opake yellow deposits interspersed through the structure, in the case of a man who died exhausted with diarrhoea brought on by hardships and intemperance, and in whose case the secretion of urine was very deficient, but whether coagulable or not I had no opportunity of ascertaining. \V hen this disease has gone to its utmost, it has appeared to terminate by producing a more decided alteration in the structure; some portions becoming consolidated, so as to admit of very partial circulation ; in which state the surface has assumed a somewhat tuberculated appearance, the gentle projections of which.were paler than the rest, and scarcely received any of the injection which was thrown in by the arteries. In this more advanced stage, if it be the same disease, dropsy has existed, and the urine has been coagulable. (Sallaway, Case III.) " The second form of diseased kidney is one in which the whole cortical part is converted into a granulated texture, and where there appears to be a copious morbid interstitial deposit of an opake white substance. This in its earliest stage produces externally, when the tunic is taken off, only an increase of the natural fine mottled appearance given by the healthy structure of the kidney ; or under particular circumstances, gives the appearance of fine grains of sand sprinkled more abundantly on some parts than others. On making a longitudinal section, a slight appearance of the same kind is discovered internally, and the kidney is generally rather deficient in its natural firmness. After the disease has continued for some time, the deposited matter becomes more abundant, and is seen in innumerable specks of no definite form thickly strewed on the surface; and on cutting into the kidney these specks are found distributed in a more or less regular manner throughout the whole cortical substance, no longer presenting a doubtful appearance, but most manifest to the eye without any preparation; and other cases less advanced, requiring maceration in simple spring water for* a few days to render them more obvious. When this disease has gone on for a very considerable time, the granulated texture begins to show itself externally, in frequent slight uneven projections on the surface of the kidney ; so that the morbid state is readily perceived even before the tunic is removed. The kidney is generally rather larger than natural ; sometimes it is increasecl'very much, but at other times it is little above the natural dimensions. " The third form of disease is where the kidney is quite rough and scabrous to the touch externally, and is seen to rise in numerous projections not much exceeding a large pin's head, yellow, red, and purplish. The form of the kidney is often inclined to be tabulated, the feel is hard, and on making an incision the texture is found approaching to semicartilaginous firmness, giving great re-6 distance to the knife. The tubular portions are observed to be rawri near to the surface of the kidney : it appears, in short, like a contraction of every part of the organ, with less interstitial deposit than in the last variety. This form of disease existed in a case rom which I had a drawing executed about three years ago, ii also existed in Bonham (Case VIII.); and a most decidedlybarked instance of it may be found in Stewart where "owever the kidney was of a lighter colour than in the other cases, which were more of a purplish gray tinge. I believe the case of Smith belonged to the same. In most of these cases . e urine has been highly coagulable by heat, at times formlng a large curdled deposit, though in one case (Castles) Where an approach to this appearance was found on the outside of the udney, but with marked structural change in the liver, and with confirmed bronchial congestion, only a dense bran-like deposit of a brown colour was produced by the application of heat. " Although I hazard a conjecture as to the existence of these three different forms of disease, I am by no means confident of the correctness of this view. " Besides these three forms of disease, passing almost into each other and usually attended with decidedly coagulable urine, there are tw? other deranged conditions of the kidneys in which the coagulation is sometimes observable, but in a very subordinate de-bfee> aud often though observable on one day is quite lost on nother. One of these morbid states consists in a preternatural tness of the organ ; the other in the blocking up of the tabular ructure by small portions of a white deposit bearing the appear-^ftce ?f small concretions. In the former a corresponding loss of rmness has been observed in the structure of the liver, and the f P een and the parieties of the heart, the action of which organ had een observed during life to be deficient in force. In the other C:*ses, besides the obstructed state of the uriniferous tubes, the "whole structure of the kidney has been somewhat deranged, the c?rtical portion firmer than natural,-and the tubular part has lost he regular convergency of the vessels, so that they have assumed j* waved direction.?It is by 110 means improbable that we shall ereafter find many other sources of renal irritation to be connected with an analogous state of the urine. t Observations on the Treatment. i i'-^n ^le f?reg?ing statements it has been my great object to es-J1 lish the fact, that certain dropsical affections depend more on le derangement of the kidneys themselves than has generally een supposed ; and that the albuminous nature of the urine frequently points out the particular cases in which these organs are le seat of disease. I wish that I were now able to add any thing completely satisfactory to myself with regard to the mode of treatlng these diseases of the kidney. It will be very obvious from a review of the cases I have cited, that they sometimes present difficulties so formidable as to defy the ordinary means of cure; in-deed I am inclined to doubt whether it be possible, after the decided organic change has taken a firm hold on the kidney, to effect a cure, or even to give such relief as may enable the patient to pursue for a few years the occupations of life ; where, however, the mischief is less rooted, we may undoubtedly do much. In the treatment of the disease, as it occurs in sudden attacks of anasarca from intemperance and exposure, in its early stages, and before organic changes have taken place, we have two distinct indications to fulfil we have to restore the healthy action of the kidney, and we have to guarcj continually against those dangerous secondary consequences which may destroy the patient at any period of the disease. " The two great sources of casual danger will be found in inflammatory affections, more particularly of the serous, sometimes of the mucous membranes, and in the effusion of blood or serum into the brain, and the consequent occurrence of apoplexy. Of these secondary or casual dangers we have illustrative examples in many of the cases which have been stated above. Out of seventeen dissections, we have found ten or eleven betraying inflammation of the pleura, generally old, but sometimes of more recent date. We have found three instances in which the patients had suffered decided attacks of inflammation in the pericardium shortly before death; and in two of these cases we had proof of some previous affection of the same kind.
In one only were the signs of inflammation in the peritoneum well marked. Five out of the seventeen had altogether escaped inflammatory affections of the , serous membranes ; and one of these died with inflammation of the epiglottis. Thus then we have proof of the frequency of these attacks ; and at the same time it is obvious that they form no essential part of the disease, since in several of the best-marked cases there has been no reason whatsoever to suspect inflammation during life, and no traces of its existence have been discovered after death. With regard to the cerebral affections coming on in the progress of these diseases, we find in the cases above related both apoplexy and epilepsy to have occurred ; and a very wen marked instance of the former was witnessed in a patient of the name of Macguire, in the Clinical ward in 1825. " Purgatives generally act well ; the Elatermm in the case of Evans evidently gave much relief; and all the saline laxatives which unite a certain degree of diuretic power are decidedly useful. Amongst these I have found the Supertartrate of Potash the most efficacious ; and the best mode of exhibiting it, when the stomach will admit, is by directing the patient to take a large draught of a mixture containing more of the salt than the water will dissolve, the first thing in the morning : and it will be seen that in some cases I have almost trusted entirely to this remedy-Where the stomach will not bear this mode of administering purgatives, the combination of Jalap, Supertartrate of Potash, and a little Ginger repeated from time to time, answers well, or even frequent doses of Castor Oil have been very useful. " The diuretic remedy which I have generally used, has been the Squill in its different forms : but it has always acted best when given in combination with Hyoscyamus, or when a grain of Opium has been prescribed once or twice a day. Indeed I cannot but consider this an important part of the treatment, with a view to diminish the irritation of the kidneys, as well as to allay the general disturbance which must necessarily result to the constitution, from the circulation of blood which has been so imperfectly acted uP?n by these organs. Digitalis has in some instances been cautiously administered with temporary advantage, and seems by its power of checking the circulation to be well adapted to those cases where the pulse is sharp, as frequently occurs throughout the whole progress of this disease. " One of the most important questions in the treatment of this c ass of dropsies, is the propriety of employing Mercury. It is potisistent with the most successful treatment of many forms of Ki matory disease, ^at we should have recourse to the valuae combination of Calomel with Opium ; and it is consistent with p may often be found coexistent. If this be the case, it is not improbable that Tonics will be the most appropriate remedies. In one or two cases of anasarca which I have lately had under my care, where from the feeble but extensive beat of the heart I was led to suppose that a feeble state of that organ existed, a combination of Sulphate of Quinine with Squill, effectually restored the patient. And .occasionally we find anasarca even with coagulable urine so marked by debility, that tonics and steel give decided relief; probably it is as a tonic that the Uva Ursi is sometimes useful." (P. 67.) Dr. Bright, however, in maintaining that the kidney is often at fault in cases of dropsy where the liver has been innamed, by no means goes so far as to assert that the state 01 the latter may not likewise be the frequent cause of effusion, even where the kidneys are quite healthy. These morbid conditions of the liver are very various ; but the most interesting, in a pathological point of view, is that in which the viscus was contracted, and throughout of a morbid structure, apparently by the deposition of minute portions of yellow matter, the surface covered by a very fine peritoneum, quite transparent, even more thin thtp usual, presented a general rough granular, and therefore uneven, surface, of what might be called liver-coloured red and yellowish gray. On being cut into, the same structure of a less red colour pervaded the whole.
The liver was thicker and rounder than natural, and rather smaller, and on pressure broke down easily with a brittle or crisp fracture, uneven and granular. The gall-bladder, opake and thick, contained the usual quantity of bile ; the common duct was pervious, but at its entry into the duodenum was contracted in a nipple-like projection, with an orifice not mucfl larger than to admit the point of a pin. On opening the gallbladder and letting out the deep-coloured viscid bile with which it was filled, a number of small yellow bodies, larger than millet seeds and soft, adhered to the villous surface of the gallbladder, chiefly on the side where it is attached to the liver. The appearances in this case led Dr. Bright to suspect that part of the structural change depended on some deposit from the bile, the small white bodies found in the gall-bladder having a certain resemblance to the whiter parts of the liver. With a view of ascertaining this point, he transmitted a portion of diseased structure to Dr. Bostock, who obtained a quantity of what appears to have been cholesterine ; but as the subject is new and interesting, we shall subjoin his letter. * Upper Bedford Place, December '26th, 1826. Dear Sir, " At your request I send you an account of some of the experiments which I made upon the portion of liver of Willoughby Taylor which you sent me >.a January last. It differed W Dr. Bright'sReports of Medical Cases. 525 )^s external characters from the ordinary aspect of this organ; ,t; had a marbled appearance, and upon being closely examined, ^vas found to consist of a number of small white granular masses, from the size of a pea to that of the most minute particle, imbedded a basis of reddish brown substance. When a thin layer of the liver was viewed in the microscope, the distinction of the two parts was still more evident, the white masses being considerably translucent, while the connecting substance was perfectly opake. CTUT1CAL ANALYSES. rose to the surface, which, when removed, was found to be of a thick consistence, unctuous, and inflammable, leaving1 after combustion a considerable portion of a light carbonaceous residuum. It was not melted by the heat of boiling water, but when held over the flame of a spirit-lamp on a leaf of platina, it immediately fused. Acetic acid threw down a gray precipitate from the potash. " 8. A portion of the liver was digested in diluted nitric acid at the temperature of the atmosphere. In six days its texture was entirely broken down, the red matter appeared to be dissolved, while the white substance was left in the form of small grains. These grains were separated from the acid and washed in water; they were found to be fusible at a temperature above that of boil' ing water, and were readily inflamed. A portion of the acid was supersaturated with ammonia ; it assumed a deep orange colour, but no precipitate was thrown down. y. Ihe substance which was procured by the action ot heated alcohol on the liver was of a thick and somewhat unctuous consistence ; it was softened but not fused by the heat of boiling water; but when exposed to a stronger heat on bibulous paper, it fused and left a greasy stain. It immediately melted by being heated over a spirit-lamp on a sheet of platina, and burned with a bright flame. When digested with pure ammonia it partially united with it and formed a saponaceous substance.
It was scarcely acted on by being heated with caustic potash, but by the addition of acetic acid to the potash after it had been filtered, a slight precipitate was thrown down. " From the above observations I think we are warranted in concluding, that the liver which you sent me for examination contained a quantity of a substance nearly resembling cholesterine, the body which forms the basis of the biliary calculi. I do not venture to determine concerning the nature of the connexion which subsisted between this substance and the liver, but I should conjecture that it had been secreted by the arteries of this organ, and deposited in its cellular texture. Believe me, dear Sir, most truly yours, 3.?The whole organ may be changed into globular conations, harder and tougher than natural, and which are easily picked out of the cavities in which they are embedded. *n a case where a portion of liver thus diseased was macerated *?r some months in water, the effect was to convert all these globular bodies into adipocere, the connecting cellular membrane undergoing no corresponding alteration.
The attention is next directed to some diseased conditions ?f the heart, and great vessels producing dropsy; but nothing Very interesting struck us on the perusal.
The different results of inflammation attacking different textures of the lungs are next considered, and the principal ?bject of our author appears to be to establish a position so ^miliar to us, that we can scarcely suppose it is not generally admitted, we mean that such a difference does actually exist, and may be recognised by the symptoms during life, and by appearances after death. -I he cases first detailed are various forms of bronchitis, a 'sease which the author justly observes is altogether distinct r?m inflammation of the substance of the lungs, and requires ^ery different treatment. We repeat, however, that we be-'eve the author is mistaken if he supposes that the opinion lv llch he advances on this subject is at all peculiar or different l?tn that generally entertained.
Under the head of termination of pneumonia in suppura-lQn, there is a very good case of simple abscess of the lungs ; in most cases where suppuration takes place from the Vl?lence of simple inflammation, it is attended by sloughing.
Gangrene of the lungs is known to be a very uncommon termination of inflammation in these organs ; probably, how-^Ver> it may occur more frequently than has been suspected. everal cases are described by Dr. Bright, in which gangrene %vas found to have taken place.?Some of these were accompanied by intolerable fetor of the breath, and appear to have lesernbled very much those cases described by Dr. Chambers,111 this Journal for September, as examples of abscess with ? oughing. The subject is much more fully entered into by r-Chambers in the paper alluded to, than by the author be-0re us.
The disorganizations of the lungs comprehended nder the general appellation of phthisis, are described with *ouch care. " The history of Phthisis Pulmonalis is unfortunately so familiar o every practitioner, that it is unnecessary to enter into a detailed narrative of symptoms. I shall satisfy myself with little more than a statement of the morbid appearances presented, when, as is ]1'ost frequent, the disease has terminated fatally ; and for this purpose the cases will be so selected as to comprise the greater part of the organic changes which usually take place. These changes v/ill be found chiefly to consist in the disorganization of the lungs, in the ulceration of the larynx, in the obstruction of the absorbent glands, and in the irritation or ulceration of the mucous lining of the intestines. Of these it may be said that the first only is essential to the disease ; but all the others are found very frequent to exist, aggravating the symptoms and hastening the fatal termination. The disorganization of the lungs, which more particularly belongs to phthisis, is generally considered to be peculiar to the disease, and to differ specifically from the disorganization which depends on simple inflammation under any of its forms : it is however not to be doubted, that ordinary inflammation has fre" quently been the immediate forerunner and even the exciting cause of phthisis, giving occasion to that morbid action which shows itself by the formation of the genuine phthisical tubercle. It will be seen in the following: cases, that the tubercular deposit assumes two totally different forms ; so that, were it not for the fact of their occurring so frequently together in the same individual, in the same lung, and even in the same lobe of that lung, we should scarcely be authorized in considering them the result of the same, or even of analogous morbid actions. It will be seen that sometimes a portion of the lung, varying from the size of a nutmeg to the greater part of a whole lobe, has become of a dense semicartilaginous consistence, has assumed a permanent blueish gray colour, and is nearly translucent; that this has gone on gradually to become yellow in spots, to soften, and to form abscesses of a sluggish character, finding their way in time to some unobstructed bronchus, and discharging themselves by expectoration. The cavity becomes larger ana larger by the suppuration of the internal surface, which appears like a secretion from a vascular tissue, with which it is surrounded; this however is not exactly the case, as there is reason to think that the cavity actually enlarges, and therefore that the internal surface must waste, and be renewed by a fresh membrane forming beneath. In other parts of the same lung a very different process has often been going on ; and a number of minute bodies, not larger than the smallest shot, have been deposited more or less thickly throughout the substance. The lung may scarcely be altered in its appearance ; but, on pressing it, hard unyielding bodies are distinctly felt ; these in a short time enlarge, and when still not larger than small peas, begin to suppurate at the centre 5 or more frequently these small miliary tubercles join in clusters, either forming masses of themselves, or inclosinga piece of the lung, which becomes hard and blue and semi-transparent, and either runs into suppuration together with the small tubercles, or, if no suppuration takes place towards the centre, becomes completely separated, and forms a slough in the midst of the cavity, which is surrounded by the tubercular matter in the form of a cyst. These are the two extreme points of the processes which take place m genuine tubercular phthisis ; and they admit of many modifications, more particularly when combined with the effusion of fibrin which attends simple inflammation. " Another of the morbid changes frequently attending phthisis is the ulceration which takes place about the larynx and the trachea.
It is often very difficult to say whether this or the affection of the *Ur*g has first existed; there is no doubt that sometimes the one and sometimes the other precedes. The occurrence of this ulceration is generally betrayed by the hoarseness of the voice and the clanging sound which accompanies the cough ; the most usual seat of the ulceration is immediately below the rima glottidis, where it begins with one or two very small round ulcers, which soon extend and become irregular in form, assuming the appearance of superficial abrasion : the situation and extent, however, VilI7 a kittle ; sometimes the epiglottis itself is ulcerated, and occasionally small independent ulcers take place in the mucous memrane of the trachea, two or three inches below the cartilages of e larynx. Where the ulceration of the larynx has taken place arly> it has not unfrequently drawn the attention both of the pa-'ent practitioner from the more important seat of disease ; for e irritation and uneasiness occasioned by this local disease in le .0rifice of the air-passage, is much more forced upon the attention, than the inconvenience and dyspnoea, seldom amounting pain, which accompany the tubercular deposit in the lungs. .' A third set of morbid appearances in phthisis are those which arise from the obstruction of the absorbent glands, more particu-arJy those of the bronchial passages and of the mesentary. In Scr?phulous subjects we often find the glandular system Tery generally disordered in connection with phthisis; but in other cases, yhere little or no glandular disease is discovered in parts which are open to observation, the glands of the mesentery are still enlarged and hardened, or have gone into a state of suppuration. This disease of the mesenteric glands appears frequently to be the immediate consequence of the irritation taking place on the mucous *-uat of the intestines ; which often exists from an eariy periou 01 he complaint, showing' itself at first by irregular action of the ?wels, by occasional diarrhoea, by the natural cleanness of the .0ngue, its glossy appearance, or the occurrence of apththse ; and the latter stages by the uncontrollable diarrhoea which hastens he conclusion of the disease. It will generally be found that the e?largement of the mesenteric glands in anyone part maintains a certain proportion to the degree of irritation in the mucous memrane of the intestine immediately opposite ; and that when ulcera-?on has actually taken place, the mesenteric glands are largest and most inclined to suppurate in the immediate neighbourhood of the ulcers. When the glands of the mesentary become obstructed, ? fresh cause of that rapid emaciation which attends phthisis un-*olds itself, and the careful examination of the part after death often explains that cause in a most striking manner. It appears that the condensed structure of the gland actually presents a mechanical obstruction to the fluid which has been separated for the nourishment of the body ; and I have found the lacteals gorged with chyle, as by the most successful injection. This is seldom seen to any great extent: but very frequently occurs partially, so that a few branches of the lacteals are beautifully traced, filled with a fluid which separates, throwing up a cream-like substance to the top, while its more watery portions remain in the lower part of the fine tubes : and by carefully following these tubes, you may sometimes trace two or three of their convolutions in the substance of the gland to which they run. At one time I was inclined to think that the lacteals were seldom found to be obstructed, except when they originated from an ulcered surface in the intestines, but this is not the case; and though, owing to the greater irritation which is set up in these parts, the glands will generally be more diseased and hence less pervious, and therefore will be most likely to give occasion to the filling of the lacteals ; yet I have sometimes traced the gorged lacteal most distinctly, from a part of the mucous membrane free from ulceration.
" The bronchial glands also, as I have before remarked, are subject to morbid affections in phthisical subjects. They occasionally become remarkably dark in their colour, firm in their consistence, and enlarged to a very unusual degree; sometimes, though rarely, going into suppuration, but much more frequently becoming the seat of an earthy deposit towards their centre. " The last seat of morbid change of which I shall speak, is the mucous membrane of the intestines. The affection of this membrane is one of the most important features in a majority of the cases of phthisis; it shows itself by unequivocal symptoms during life, and is traced in two different forms after death ; sometimes giving proof of a amused irritation along the whole membrane from the pyrolous to the termination of the rectum, evinced by increased vascularity or by the appearance of innumerable minute black specks, which give a general gray colour to all the parts where they are most frequent, and sometimes affording evidence of a more severe affection, by the formation of numerous ulcers, which are found sometimes in the upper part of the duodenum, frequently dispersed along the whole course of the intestines, but usually most abundant about the valve and through the whole extent of the colon. These ulcers, as found in the small intestines, are usually in the first place very small and circular, and appear to originate from round opake white bodies about the size of half a sweet-pea ; but whether these are altogether morbid tubercular deposits, or are only enlarged mucous glands, it is no easy matter to decide : certain it is, that they are most generally placed in that part of the circumference of the intestine which is most distant from the mesentary, and where the mucous follicular structure is most developed. These ulcers often extend to the size of a shilling, and sometimes still further, in a lengthened form. It is remarka-that the edges are often thickened by an opake white matter deposited beneath the membrane and drawing it into a puckered form; and sometimes this deposit is seen in the middle of the ulcer, like ? granulation on its surface. The ulceration of the large intestines ls usually the most remarkable, and it varies a good deal in its character ; in general it is by far the most conspicuous about the c?ecum and the valve of the colon, where it appears to commence Jttuch as in the small intestines, by opake deposits ; but these are *r?m the beginning more numerous, and it goes on to a much greater extent, sometimes involving the coecum in one continued J^cer ; this occasionally, though rarely, affecting the lining membrane of the vermiform process itself. In other parts of the colon, as along its arch, the ulceration usually assumes a more regular nd uniform character that in the ccecum ; for we generally find a enes of oval ulcers with elevated edges, more or less closely dis-1 uted along the sides of the longitudinal bands, and apparently ?termined in the direction which they take, by the transverse folds . "e mucous membrane. These ulcers frequently continue to the ^gnioid flexture, and occasionally even to the rectum. It appears that they sometimes undergo a process of healing, their tuto r?U edges softening down, and their flattened edges adhering "e parts which have been denuded by the ulceration ; but this i1!0.1-.3 frequent occurrence, because the more usual course of P "'sis is to go on from worse to worse till it terminates in death ; little attempt has usually been made by practitioners to change e condition of the intestines, while they have felt that the more r?ent disease was in another part." (P. 148.) one of the cases of phthisis, which does not appear to ave presented any thing remarkable in the symptoms, the ?0rta and some of the arteries were found to be of a bright red ln tern ally ? we remember to have heard the late Mr. Shaw state, that he had frequently seen this in the bodies of persons rought to the dissecting-room, who had died of phthisis pul-Two cases follow, which are intended to show the effects of pecacuanha and mild Mercurials in dysentery: we believe fact will be readily admitted. *he rest of the volume is occupied with an account of the forbid appearances which present themselves in the intestines I Uring the progress of fever, and on the method of treatmentjto e adopted. The readers of this Journal are, or ought to be,well acquainted with this subject already, as it has been fully discussed in the papers of Dr. Chambers and Dr. Hewett. The observations of Dr. Bright, both as to pathology and practice, are confirmatory of those already made by these gentlemen, and the Accordance between physicians to different hospitals thus mani--teclgi^ additional strength to our belief of their accuracy.
Dr. Bright's views differ in any important point, we should lay them before oar readers and contrast them with the others, but such not being the case, we consider that to enter upon the subject further would be a work of supererogation. The pathological points are illustrated with fifteen highly finished engravings.' Some of them are extremely good, but others are comparatively inferior; and, upon the whole, we think the colouring exaggerated. They are by no means so good as the plates in Dr. Hooper's work on the brain, although the volume is proportionally more expensive.
A Treatise on the Cutaneous Diseases incidental to Childhood', comprehending their Origin, Nature, Treatment, and Prevention. By Walter C. Dendy, Surgeon to the Royal Infirmary for Children, &c.?8vo. pp. 289. Churchill, London, 1827.
The errors of the ancient writers upon the subject of cutaneous affections have been so very frequently the theme of modern criticism, that it cannot be necessary we should (to adopt the language of Mr. Dendy,) " turn the sail of our investigation up the stream of time!" in order to discover the precise extent of their knowledge. It is confessed that the terms formerly employed to designate diseases of the skin were very loosely and indiscriminately applied, and that, in consequence, the treatment adopted was equally deficient and inappropriate.
If, however, the labours of the learned of olden times effected but little in this branch of medical science, it has received considerable improvement at the hands of different modern authors, whose names and works are too well known to require any formal eulogy from us. 1 he arrangement of Mr. Plumbe, as well as the classification lately presented to us by Mr. Rayer, are considered by the author " as very correct elucidations of the character of cutaneous diseases; but, as the nosological arrangement should, in my opinion, present an epitome, as it were, of the Treatise, I think the combination, for example, of all cutaneous inflammations, whether acute or chronic, essential or symptomatic, in one chapter, by Mr. Rayer, must occasion some confusion with regard to the modes of treatment; while, in Mr. Plumbe's arrangement, certain diseases are unnecessarily disjoined." (P. 6.) Mr. Dendy deals more mercifully with Alibert than the late Dr. Bateman, who declared that the French writer, with all his boasting, " had contributed nothing to the elucidation of the obscurity" in which the subject had been previously veiled. Mr. D. confesses that Alibert stands high 511 the rank of writers on cutaneous diseases, but that, in consequence of his imperfect classification, his brilliant work must " moult some feather of its value." Mr. Dendy almost implicitly adheres to the phraseology of Dr. Willan.
The author has more than once regretted the local success ?f his applications to the crusts of porrigo, the removal of Which lias been speedily followed by acute ophthalmia, which Wlthout great care would have proceeded to the rapid disorganisation of the globe; and he presumes we may often trace the occurrence of severe cerebral affections to the merely jocal treatment of porriginous or impetiginous crusts. We have more than once had occasion to touch upon this question. It has never fallen to our lot to lament the success of ?Ul" local treatment in cutaneous affections, provided the bowels were acted upon by occasional purgatives at the pe-llQd of their subsidence. Jt is true that Dr. Darwin has presented us with two c.ases of chorea, and one of hepatic disease, immediately succeeding the cure of scabies, and that a few other similar instances have been recorded. But when we consider the immense number of cases of that, and many other eruptive leases, which are cured by the popular application of local nieans, and the very few examples of subsequent and connected constitutional injury, we are inclined to be a little C?ubtful of the fact. We, perhaps, too frequently argue upon the principle of post hoc ergo propter hoc / the falacy ?f which sophism the author deprecates upon the subject y the virtues ascribed to many remedies. The proof of the anger above alluded to would be the frequent occurrence of institutional disease after the removal of cutaneous affections. \ye should not, ourselves, allow the few cases of the aD?ve kind which have been related to have much weight in ?ur practice. We should require very unequivocal evidence 0 the connexion between the removal of the disease of the and any subsequent general malady which may occur. must be granted, " that from the recession of the specific exanthemata, as rubeola and scarlatina, we may usually anticipate an aggravation of the febrile symptoms," and somenies even dangerous visceral diseases; and we perfectly agree Jth Mr. Dendy, "that the administration of internal remedies is almost universally essential in the treatment of cutaneous diseases: indeed,indispensable in those of chil-The author has been anxious to dwell much on infantile expression, " as infantile disease has been too much con-A'?-346?No. 18, New Series.
3 Z signed to the often superstitious and bigotted priestess of the nursery, from an absurd idea that it was useless to attempt to investigate disease where words were wanting to develop the sufferings of the patient." We were really not aware that the profession were exposed to such an accusation of negligence and folly. ? The author justly presumes, that, with but a limited list of remedies, we may affect more, with an attentive consideration of constitution and the cause of disease, than with the whole materia medica at our disposal, assisted only by a superficial and confined view of the malady with which we have to contend.
From the conviction that the majority of infantine eruptions are symptomatic of constitutional or intestional disease, Mr. Dendy has deemed it proper to offer some remarks on the establishment of the healthy condition of the functions, which may be considered as constituting the prevention of cutaneous diseases. In this section we find many judicious practical observations, which have, however, been much too frequently noticed to require any particular comment.
The error of feeding children to excess would rarely he committed if the advice of the medical world had its proper influence on the public. But, in spite of all our rhetoric and remonstrance, mothers will still be found who will persist in stuffing their children, or, as Mr. Dendy expresses it, who appreciate them " as they would their capons or their pigs> by the mass of matter which composes them." We enter upon the more immediate subject of the volume, by the consideration of those cutaneous diseases symptomatic of disorder in the alimentary viscera. Mr. Dendy observes, that the papulae of strophulus " are often materially modified by the peculiarity of constitution and mode of living: indeed, by these causes, and by neglect, it may be totally changed from its first simple form to one even of contagious nature. From this source arise the peculiarly aggravated cases o? eruption among the children of the indigent, in whom the simple strophulus will sometimes degenerate into the contagious scabies." (P. 80.) We suspect there is some error in this opinion. From bad feeding and disordered secretions, that common and ge' nerally trifling disease, strophulus, may, we know, be much exasperated. There may exist a considerable degree of itching, pain, and excoriation; but we should still doubt the contagious nature of the disease, however aggravated it may become from accidental circumstances. A very brief account is given of prurigo, crusta lactea, follicular tumors, phlegmonous tumors, urticaria, impetigo, and "erpes; and we then arrive at " Disease, symptomatic chiefly of deranged chylopoietic functions, usually marked by debility." jyjr> J)endy is of opinion that purpura hemorrhagica ls usually dependent upon a debilitated and deranged state ?f the system. Some pathologists have referred the ecchy-^osis to increased vascular action, which they have termed the hemorrhagic effort. We believe our author has formed a correct view of the subject, although cases may occasionally ?ccur characterised by such symptoms as to support the con-trary^doctrine. Mr. Dendy argues, that? * rom the absence of acute fever, the condition of the pulse, ?d the languid state of the system, inducing often syncope on exertion, occurring, however, without previous excitement, it may e termed a disease of debility, depending on a want of the elastic Property of vascular coats, allowing the blood to break through le capillaries : a doctrine in opposition to the opinion of Dr. arry, who asserted its inflammatory nature. In what is designated petechial fever, however, which I have never seen in chilthe vascular action may be much increased. On the first e usion of the blood, it is often of a florid hue, but it speedily becomes purple, assuming a brownish tinge as it is about to be ree?0Ved by absorption. The cuticle above the spots is slightly finV;Jtet! and smooth; sometimes, however, it is raised in vesicles ed with purple blood. In purpura hemorrhagica, as well as 15 orbutus, the mucous surfaces are often more affected than the external skin, the danger being then materially increased, as the , 'cate epithelium is easily burst by the extravasated blood, and 'us we have hemorrhages from the gums, the throat, &c. which lave given the specific name to this form. Internal hemorrhage may thus take place, which sometimes prove fatal. It is rare that hemorrhage takes place on the surface of the body, but in some cases the slightest pressure will produce ecchymosis, and firm compression will break the cuticle, and the blood will flow from , lesion. I have seen children evince this petechial tendency, ueing spotted black by the slightest braises. The extravasation in Very extreme cases will sometimes occur from the mere muscular action of a limb. Blood will sometimes flow from the eyes, nose, i? mouth of children, at the same time that they expectorate ?ody mucus, and pass bloody stools resembling melsena, constmg only of sanious coagula mixed with intestinal mucus, fif kS6 aPPearances usually occur in children about the fourth or year.
In protracted cases, where internal hemorrhage has ot speedily proved fatal, we see the blood gradually become paler, ntil at last the hemorrhage will scarcely stain the linen on which drops; the ecchymosed spots being subject to the same faded Liange; the circulating fluid appearing to assume almost the character of serunn The cases which generally prove rapidly fatal, are those in which hsematemesis, haematuria, or hsemoptoe occur, the effusion being both obscure and out of the reach of any mechanical pressure. In similar cases the heart and liver have been found very pale in their internal fibrous or parenchymatous structure, a livid colour appearing under their internal membrane." (P. 143.) For the removal of this species of purpura, we must chiefly rely upon the judicious use of mercurial purgatives. Some caution, however, is required. " Mercury should not be continued long in purpura, as it has usually a tendency to depress power, although some physicians recommend it even to ptyalism." The author next speaks of " diseases usually symptomatic, arising also from extraneous excitement; depending probably on peculiar idiosyncrasy." As in the former section, we pass over the descriptions given of many different species of cutaneous disease, because we find them to be merely superficial abstracts of opinions and statements that have frequently been repeated. We differ from Mr. Dendy upon the treatment of porrigo favosa, which he states, " even in those cases which arise from actual inoculation, should be chiefly internal." That internal remedies are necessary in this very obstinate form of skin-disease, we readily admit; but we know, also, that quite as much depends upon the local applications, of which the best are (as stated by the author) poultices at the commencement of the disease, and, on the subsidence of inflammatory action, the Ungt. Picis p.j. Ungt. Sulph. p. 2. In some very stubborn cases, Mr. D. has found equal parts of nitric acid, oil, and water, very efficacious.
Upon the subject of porrigo suctulata, we agree with Dr-Underwood and Mr. Plumbe. We do not remember a single case, out of very many we have had under our care, which the disease of the surface appeared to be connected with constitutional derangement. Mr. Dendy thinks otherwise, and assigns a double origin to this complaint. The following ointment has been found very efficacious in this disease:* R-. Sod. Alicant. 3iij.; Potass. Sulph. jiij.; Adip. ^iij-It is to be applied daily after the employment of poultices.
A decoction of tobacco has been used-as an external remedy? but this must be employed with caution, as death has occurred from its injudicious use. * Fornuslaire Pratique des HApitaux Civils de Paris.
We cannot pass over the subject of " fungous excrescence" vou'nd the root of the nail, without expressing our approbation of the manual dexterity shown by Mr. Durlachre, in his excellent operation for the removal of this disease. We have twice seen Mr. D. operate, and in neither case did the patient coniplain or appear to suffer pain. It must be needless to observe, that the rude and unscientific operation of tearing away the nail, as it is even now sometimes practised, inflicts ^e most severe torture. Mr. D.'s operation "consists in cautiously cutting through the nai? with a very small knife, and without dividing or wounding the cuticle interposed between its under surface and the sensitive structure beneath It; then, with a minute pair of forceps, raising and detachlng the nail. The operation is productive of little or 110 pain, and is eminently successful." ' diseases consequent to specific infection," come next.? /e l]ave but one remark to offer upon the sketch which the au-*?r has given of Rubeola. It is stated to occur butonceduring e* To this general fact, however, there are occasional excep-0ns :7-we have ourselves, in two instances, seen measles a second time in the same subject; and numerous cases were published by the late Dr. B a illie, the accuracy of which there can e no doubt. Mr. Dendy has nothimself made any experiments j^pon the inoculation of measles, " but it has been advocated arrangement and verbal description of the various maladies touched upon, which are just sufficient to rescue the author from the charge of having copied his matter from others who have before published upon the same subject. There was certainly no vacant niche in the professional library for the book Mr. Dendy has presented to us. The substance of ri may be found in most works which treat of the diseases of infants; and, in either Bateman or Plumbe, we have much more satisfactory descriptions of the cutaneous diseases which are here rather superficially considered. The duty of reviewing is never more unpleasing to us than when we are compelled to withhold our praise; but, from misplaced commendations, the conclusion is non melius de laudato, pejus de laudantc- EiGHT-hundred-and-five royal octavo pages on the pulse! the work should have been written last century. We sat down to the perusal with every disposition to be pleased, and every wish to be instructed : we had heard the author fa" vourably spoken of, and knowing him to be a foreigner, vve were desirous of showing him courtesy. But we have a higher duty to perform?we must be candid. In our ju(}g~ ment, then, the work is very much laboured?very speculative for the purpose of the still farther prosecution of his researches." The short sketch of his history with which he has presented us, will show how much the author has been in earnest, and what sacrifices he has made in the progress 01 his object. It has been supposed, indeed, that circumstances of a political nature had led to his abandoning his ?ative country; but, as he expressly states his exile to ? " voluntary," this idea must be unfounded, although it cerainly would have accounted more rationally for his giving the anatomical chair at Naples, and wandering over the small in the first; elevated, full, and strong in the second ; and slow, rare, and hard in the third. The pulse is, in fact, quick, frequent, and small in children ; elevated, full, and strong in adults; and slow, rare, and hard in old persons. But it is not sufficient to know, or to say, that the pulse is quick, frequent, and small in children; elevated, full, and strong in adult age; and slow, rare, and hard in old persons: to this information it is requisite to add the knowledge of the fact, that the celerity, frequency, and smallness of the pulse in the period of infancy vary in degree and strength ; that the same takes place with respect to its elevation, fulness, and strength in adult, and its slowless, rarity, and hardness in old age." (Vol. i. p. 151.) The second volume is that from which we expected to derive most information, as it relates to the Morbid Conditions oi the Pulse. These are divided into the diagnostic, organic, and critical.
The diagnostic pulses are successively treated of under the heads of the " Great Morbose Pulseand the " Small Morbose Pulse;" and a general idea of the author's opinions may be gathered from the following analysis of the inferences drawn from different kinds of pulse. " 1st. If the pulse, from being small, becomes suddenly great, without the strength of the patient being improved, it is a sign of death in lethargy and apoplexy, according to the observations of Baglivi and Wapfer.
v. " 2d. The change of the rare and slow pulse into quick and frequent, is a favorable sign in ataxic fevers and liYPOsthenic dis* eases. % " 3d. The softness and rarity which succeed the excessive hardness and frequency of the pulse in acute hyposthenic fevers, is an excellent sign. " 4th. According to the observation of Actuarius, the elevated, vehement, and quick pulse announces the commencement of a disease in one or more vital organs ; and the small, frequent, an" weak pulse indicates, on the contrary, the long duration of a dlS' order, which finally succeeds in impoverishing and overpowering the vital powers. " 5th. The thinness, frequency, and hardness of the pulse sho\v the state of irritation, or crudity, as it is called by medical praC' tioners. If the pulse continues thus in the successive periods ot acute diseases, after the epocha of the concoction, it is a sign evidently unfavorable ; for it is then supposed that the crisis has no1 taken place there, or that, if it does take place subsequently, lt; will not be true or salutary. . " 6th. The frequent, small, irregular, and thin pulse, whilst it generally indicates the concourse of spas'm, irritation, and weak" ness, is also the worst sign in pestilential fevers, in typhus, 1? spurious angina, in false peripneumonia, and in epidemic dysen* teries. " 7th. The sudden change of the great and full pulse into the *requent, small, thin, and irregular pulse, is a fatal sign in acute diseases.
8th. The greatness and fulness which succeed to the smallness, weakness, frequency, and irregularity of the pulse, is a sign undoubtedly favorable in acute diseases.
. ' 9th. The pulse which vacillates and changes its form every distant, is always a fatal sign. This vacillation, when it exists, is observed at one time strong, at another time weak, at one time rare, at another frequent, at one time quick, at another slow : when the pulse thus vacillates and changes, it is a sign that the Pencardium, or the heart, or even both, are affected by inflammation. " 10th. When the beating of the pulse becomes very sensible hroughout the whole of the arterial tree, in the presence of acute peases, it is "an unfavorable sign, because such a phenomenon prises from the deep and general inflammation which is precisely ^dicated by this sensible beating throughout the whole arterial " Hth. The frequency, weakness, and inequality of the pulse is an unfavorable sign, as it indicates the organic affections of the reast, according to Hoffmann's observations. 12th. The smallness, rarity, and weakness (approaching to ^sensibility) of the pulse, is an unfavorable sign, especially in syncope. 13th. The pulse which grows weaker, proceeding from the Neatness to the insensibility of its oscillations, is the worst sign, as 't indicates the successive exhaustion of vitality." (Vol. ii. p. 104.) The organic pulses are those which, by some peculiarity of Tk rac^er' P0*11*-ou^ the particular organ which is diseased.
he author evidently feels this to be a weak point, as he declares his intention not to notice those who assert " that f"e doctrine of organic pulses is nothing but the produce of imagination." We have an organic pulse for the head, the hroat, the chest, and?the nose; after which follow those for e abdominal and pelvic viscera. We were rather sceptical to the nose, but it is quite obvious that our author has no uoubt about the matter, as will appear from the following passage, which at the same time will serve to show the vagueness and unsatisfactory nature.of the whole hypothesis. ' In fact, the existence of the nasal organic pulse is certain in 6 presence of local affections of the nostrils or of the nose. The Pulsatile artery generally loses its cylindrical form; for, whilst its posterior and middle or central part, which correspond to the point of the little, annular, and middle fingers, rises in the form of a small hillock: its anterior, or digital part, on the contrary, appears to flatten itself, like a small nervous riband, under the tip . No. 34s?No. j 8, New Series. of the index finger: thus, it is in this track of the flattened artery that we perceive in motion certain round bodies, similar to so many drops of water, which come driven with force against the apophysis of the radius, and from which the shock appears to be transmitted to other drops which follow the first. At other times a kind of formiculation is felt, or otherwise the impression of a movement of only two round and large bodies, which run rapidly against the index finger." Of the critical pulses, we shall say nothing, being infidels on the subject of crises in general.
We regret much that we can say nothing very favor* able of Dr. Rucco's work; for it must have been attended with prodigious labour, and the sacrifices he describes himself as having made in the prosecution of his object have been very great. He appears deeply read in tlie older meuio?* writers, and makes constant reference, among others, to Galen, whose authority he seems to look up to with great reverence.
But the admiration of Galen is not quite so great among us, and we remember, on a recent occasion, to have heard a public lecturer, who, desirous of illustrating the absurdity of wild hypothesis?of substituting words for ideas, gave a quotation from Galen as affording the most appropi"1' ate example.
A work on the Pulse certainly might be made very useful? but then it ought to be a simple detail of the signs it affords, without any attempt to carry these to a degree of refinement, which is plausible perhaps in the closet, but wholly inapplicable at the bedside of the patient. Mechanics; and we cannot give our readers a better idea oi j^ese, than by making some quotations from the work be_ After some introductory observations, in which it is pointed 1 , w ' V 1 ut tnat the contrivances for protecting vital organs are not absolute securities against accident, but that they are calcujated to meet all the circumstances of ordinary life, the author Proceeds to illustrate the subject, by comparison with some the many mechanical contrivances of art. Men proceed in a slow course of advancement in architectural, or mechanical, optical sciences ; and, when an improvement is made, it is j?und that there have been all along examples of it in the animal J?c'y, which ought to have been marked before, and which fright have suggested to us the improvement. Assuming iat the head is the noblest part, the author commences with 1 ? and the manner in which this part of the subject is handled, may be taken as an example of the whole.
It requires no disquisition to prove that the brain is the most -sential organ of the animal system, and being so, we may preoie that it must be especially protected. We are now to inquire this main objected is attained? b i must first understand that the brain may be hurt, not only hy s"arp bodies touching and entering it, but by a blow upon the theC iW^c^ shall vibrate through it, without the instrument piercing sh n U Indeed, a blow upon a man's head, by a body which Ino cause a vibration through the substance of the brain, may or?le effectually deprive him of sense and motion than if an axe a sword penetrated into the substance of the brain itself, tri ' PPc!s'n?' that a man's ingenuity were to be exercised in convmg a protection to the brain, he must perceive that if the case re s?ft, it would be too easily pierced ; that if it were of a glassy ature, it would be chipped and cracked; that if it were of a subance like metal, it would ring and vibrate, and communicate the c?ncussionto the brain. ^ Further thoughts might suggest, that whilst the case should made firm t0 j-ggist a sharp point, the vibrations of that circular se might be prevented by lining it with a softer material; no bell uid vibrate with such an incumbrance the sound would be iff0 ringing ?f a glass by the touch of a finger. We now perceive why the skull consists of two plates of bone, e external, which is fibrous and tough, and one internal, dense to such a degree that the anatomist calls it tabula vitrea (the glassy table.) " Nobody can suppose this to be accidental. It has just been stated, that the brain may be injured in two ways : a stone or a hammer may break the skull, and the depressed part of the bone injure the brain; whilst, on the other hand, a mallet struck upon the head will, without penetrating, effectually deprive the brain of its functions, by causing a vibration which runs round the skull and extends to every portion of its contents. " Were the skull, in its perfect or mature state, softer than it is, it would be like the skull of a child ; were it harder, than we find it is, it would be like that of an old man. In other words, as in the former it would be too easily pierced, so, in the latter, it would vibrate too sharply and produce concussion. The skull of an infant is a single layer of elastic bone; on the approach to manhood it separates into two tables; and in old age it again becomes consolidated. During the active years of man's life the skull is perfect: it then consists of two layers, united by a softer substance ; inner layer is brittle as glass, and calculated to resist anything penetrating; the outer table is tough, to give consistence, and to stifle the vibration which would take place if the whole texture were uniform, and like the inner table. " The alteration in the substance of the bones, and more particularly in the skull, is marvellously ordered to follow the changes in the mind of the creature, from the heedlessness of childhood to the caution of age, and even the helplessness of superannuation-" The skull is soft and yielding at birth ; during childhood itlS elastic, and little liable to injury from concussion ; and during youth, and up to the period of maturity, the parts which come in contact with the ground, are thicker, whilst the shock is disperse* towards the sutures (the seams or joinings of the pieces,) which are still loose. But when, with advancing years, something tells us t? give up feats of activity, and falls are less frequent, the bones l?se that nature which would render concussion harmless, and at leng the timidity of age teaches man that his structure is no longer adapted to active life. , " We must understand the necessity of the double layer of the skull, in order to comprehend another very curious contrivance-The sutures are the lines of union of the several bones which f?rIIl the cranium, and surround and protect the brain. These lines of union are called sutures (from the Latin word for sewing), because they resemble seams. If a workman were to inspect the joining0* two of the bones of the cranium, he would admire the minute dovetailing by which one portion of the bone is inserted into, and surrounded by, the other, whilst that other pushes its processes or juttings out between those of the first in the same manner, and the fibres of the two bones are thus interlaced, as you might interlace your fingers. But when you look to the internal surface, you see nothing of this kind; the bones are here laid simply in contac > and this line by anatomists is called harmonia^ or harmony : architects use the same term to imply the joining by masonry. Whilst anatomists are thus curious in names, it is provoking to find them negligent of things more interesting. Having overlooked the reason of the difference in the tables of bone, they are consequently blind to the purpose of this difference of the outward and inward part of a suture. " Suppose a carpenter employed upon his own material, he )yould join a box with minute and regular indentions by dovetaillng, because he knows the material on which he works, from its ^oftness and toughness, admits of such adjustment of its edges. 1 be processes of the bone shoot into the opposite cavity with an exact resemblance to the foxtail wedge of the carpenter?a kind of tenon and mortice when the pieces are small. " But if a workman in glass or marble were to inclose some precious thing, he would smooth the surfaces and unite them by cement, because, even if he could succeed in indenting the line of union, he knows that his material would chip off on the slightest vibration.

"
The edges of the marble cylinders which form a column are, for the same reason, not permitted to come in contact; thin plates lead are interposed to prevent the edges, technically termed arrises, from chipping off or splitting. " Now apply this principle to the skull. The outer softer tough table, which is like wood, is indented and dovetailed ; the inner glassy table has its edges simply laid in contact. It is mortifying see a course of bad reasoning obscure this beautiful subject. , ey say that the bone growing from its centre, and diverging, oots its fibres betwixt those which come in an opposite direction; us taking one of the most curious provisions of nature a thing accident. Is it not enough to ask such reasoners, why there is n?t a suture on the inside as well as on the out? ' The junction of the bones of the head generally being thus exact, and like the most finished piece of cabinet work, let us next lnquire, whether there be design or contrivance shown in the manner in which each bone is placed upon another." (P. 3.) . The mechanism of the spine, of the chest, of the bones and Joints, of the tendons, and of the muscles, is discussed in the same interesting manner, and the subject illustrated by Numerous excellent cuts.